THE DEMENTORS IN OUR SYSTEMS

I don’t speak out much any more about quality of care in medicine, mostly because I am out of date. But I am not out of data.

Last July, I had a sudden dysrhythmia. I was minding my own business one evening, checking a sunflower, when I stood up and started noticing my pulse pounding irregularly. I had no pain, and at first I thought it was a bunch of PVCs, premature contractions, although they were a little different. I was alone, didn’t want the animals to be uncared for if I were admitted, so I did the next best thing. I went to bed. I awoke at 1 am and felt fine.

I saw my PCP the next morning, who had had a cancellation, and my EKG looked fine. She recommended a Holter Monitor, so I wore one for 48 hours, during which time I hiked and had no symptoms. The monitor showed a few supraventricular rapid beats, nothing solid, but not normal, either, so I was told I would need to see a cardiologist, and a referral sent.

Ten days later, I had no appointment. On my own, I stopped all caffeine and chocolate, and the few funny sensations I had had vanished. Unfortunately, so did my referral. An email to the office went unanswered for a week, until my PCP replied, asking me what the cardiologist said. Well, I wrote, maybe he or she had said something, but not to me, since I had no appointment. She apologized and within a few days I had an appointment 5 weeks later, nearly 8 weeks after my event.

I saw patients as emergencies the same day who had a 10 year history of the same headache with several normal CT scans. I have a dysrhythmia as a 66 year-old and it takes 8 weeks to see a cardiologist? It’s a different world today.

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Later, my wife needed a GI evaluation. A referral was faxed to the specialist’s office, and we were to get called back. The office of the referring physician was about 150 meters away, as the crow flies, from the office of the new physician. Two weeks later, we had heard nothing. My wife called, and nobody knew where the referral was. This sounds familiar.

My wife and I are not mildly or moderately demented, we are educated, knowledgable about medicine, and can afford our care. What happens if one is demented, uneducated, or unclear about the medical system? Most people are unclear. I certainly am, and I practiced medicine. Perhaps these people think (1) nothing needs to be done, (2) the physician wants money up front and they hadn’t paid in advance, (3) somebody had changed their mind, or (4) they might not have assumed anything, just forgotten about the referral, since they didn’t have it on our mind and didn’t follow up.

Sort of like what happened to those who sent the referral.

A phone call was answered pleasantly, and my wife was told the referral would be faxed over to the other physician’s office that day, there would be “three business days” to set up a future appointment, and then she could have the procedure. With all due respect to electricity, I can walk a referral over almost as fast and with complete certainty deliver it to the right person. With all due respect to the fact my style of practice isn’t done today, “business days” is redundant. Every day was a “business day” for me. I told my wife that we were going to go to the physician’s office that day. It was a 15 minute drive, and there is something about a face-to-face interaction that gets things done quickly. It’s far more difficult to ignore a person, unlike a call, e-mail, SMS, or some other electronic medium of communication.

We bypassed everything possible and had the appointment 46 hours later, one business day, to those who count such things.

The same week, I discovered my monthly medications had no refills. I sent an email through the online patient portal and waited a week to hear. Nothing. I called the pharmacy, and they had received nothing but would call the physician’s office. I waited another week, now two weeks late in getting my medications, and called the pharmacy to see if my prescriptions were ready. I heard a “prescription” (indefinite article, singular) was ready, and when I stopped by, indeed, one was. The second one? Nowhere to be found. The pharmacy tech was pleasant enough, however, saying she would call it again to the doctor’s office. Before she called, I asked to see the dose, having changed it several months earlier. It was the original amount.

Fortunately, I had plenty of the medication at home, since the pharmacy had not changed the dose, despite my having asked them to do so. Two days later, I got a call from the pharmacy, telling me that they had been unable to reach the physician’s office. So much for pharmacies’ calling physicians successfully. I called and talked to an answering machine. I would have walked over, but I figured I had a week to burn. I still haven’t received the drug.

None of these three issues was serious. Sadly, none of them is rare, either. These sorts of things on a daily basis are Dementors, for they suck the happiness out of people. Time spent fixing these problems is time that can’t be spent doing something more important, like promptly scheduling a patient, rather than have them wait on hold, which we all do.

There needs to be a better way to track referrals. I can log on to Amazon, UPS, or USPS and immediately know the status of a package that I ordered thousands of miles away, yet I can’t find out in my own small city whether my referral has been seen by the specialist or where my medications are. What happens if somebody is elderly, infirm, doesn’t hear or see well, and needs specialty care? We are up in arms about the Affordable Care Act, yet virtually everybody is silent about the many broken systems in medicine that affect everybody in the country who seeks care, which is about all of us. Am I just incredibly unlucky? I doubt it.

As for pharmacy issues, I find it ironic I am having the same problem that my op-ed in the local paper addressed: pharmacies must start using the state error reporting system. Oregon is the only state that includes pharmacies, but the 721 last year reported exactly 20 errors. I alone have had three, and there are nearly four million people in the state. I don’t think I am incredibly unlucky. What happened after my op-ed? Choices: (1) few read it, (2) pharmacies jumped on board and are reporting like mad, or (3) nobody really cares, because we have high quality care. A=1; B=2,C=3, D=1,3. You choose.

Every broken system has countable and uncountable costs. The countable ones are hours spent doing things twice, looking for something, fixing what is wrong, and spending time apologizing. The uncountable ones are Dementors: annoyance, unhappiness, feeling of powerlessness, the wondering why, after so many years of stating what we need to do in medicine, why it still hasn’t been done.